MEDICARE: MRS. RAQUEL MARIA LOGAN-BASKETT C.O.T.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	004893-1	NY

General Provider Information

NPI Number	:	1396051256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RAQUEL MARIA LOGAN-BASKETT C.O.T.A

Provider Business Mailing Address
First Line	:	20 WENDELL ST
Second Line	:	APT. #6F
City	:	HEMPSTEAD
State	:	NY
Zip	:	11550-1206
Country	:	US
Telephone Number	:	516-385-1886
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 BEVERLEY RD
Second Line	:	APT. UNIT LT
City	:	BROOKLYN
State	:	NY
Zip	:	11218-3153
Country	:	US
Telephone Number	:	718-972-6561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2010
Last Update Date	:	08/28/2010

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